Provider Demographics
NPI:1669903910
Name:NORTHERN KENTUCKY SMILES
Entity type:Organization
Organization Name:NORTHERN KENTUCKY SMILES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:STULL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MS
Authorized Official - Phone:859-282-8844
Mailing Address - Street 1:1481 CAVALRY DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042
Mailing Address - Country:US
Mailing Address - Phone:859-282-8844
Mailing Address - Fax:859-283-8742
Practice Address - Street 1:1481 CAVALRY DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-282-8844
Practice Address - Fax:859-283-8742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1275552408OtherINSURANCE
KY1104831759OtherINSURANCE
GA1124151048OtherINSURANCE